1. Technical Field
The present invention relates to prescription benefits and, more particularly, to a method and system for managing prescription benefits coverage.
2. Description of the Related Art
Various employers offer healthcare coverage to their employees. The healthcare coverage will typically include the cost of prescription drugs (or products), in whole or in part. The healthcare coverage can also cover the cost of certain treatments. The type of prescription coverage offered to the employee can vary depending on the particular healthcare provider selected by the employer. The specific coverage offered to an employee can depend on several factors, including the particular coverage program negotiated by the employer. For example, the benefits available can be different depending on the medical coverage desired, the prescription medication available, etc. Furthermore, the specific benefits requested will directly effect the coverage cost.
Regardless of the coverage, the healthcare provider will place certain restrictions and/or limitations on the prescription medication available. These restrictions determine whether the healthcare provider will cover the cost of a prescription claim in full or in part. For example, the healthcare provider may cover the cost of a prescription claim in full, if the employee is willing to substitute a generic form of the prescribed medication. The cost of the prescription can be subsidized to different degrees, depending on the type of coverage, for example, if the employee prefers to use a brand name form of the medication.
Oftentimes, the healthcare provider will negotiate actual medication costs with one or more pharmaceutical companies in order to arrive at a coverage plan which best satisfies the budgetary requirements of the employer. For example, depending on the size of the healthcare provider or employer, various discounts can be allowed if a certain number of patients subscribe to the plan. Costs can be controlled by substituting generic forms of a drug (i.e., product) in place of name brand form. Costs can also be controlled based on the drug (i.e., product) used to treat a particular disease or condition.
Implementation of a healthcare coverage plan requires administrative procedures to address circumstances when a patient requires specialized treatment and/or medication. While such treatments may be supported by the coverage plan, the extent of coverage may be limited due to, for example, a very low rate of occurrence. Healthcare providers can conduct negotiations with employers in order to reach an agreement on how the coverage plan will address these special circumstances. These negotiations can often include guidelines for dealing with coverage of special medication and/or treatment not desired by the employer due to, for example, higher costs. For example, the coverage plan can require that a patient seek alternative forms of treatment prior to obtaining coverage for a specialized medical procedure. The patient may also receive coverage for certain types of drugs (i.e., products) only if alternative drugs have been tried unsuccessfully.
Healthcare coverage plans must also provide patients with an avenue for dispute resolution/mediation of claim denials for coverage of treatments and medications (e.g., coverage denials), whether basic or specialized. This can be in the form of an appeal or review process which examines the underlying circumstances for denying coverage of the treatment and/or medication. The specific details for dispute resolution and mediation must also be negotiated between the employer and healthcare provider as part of the coverage plan.
Healthcare providers can face difficulties in managing coverage plans depending on various factors. For example, a healthcare provider may render services to a number of employers, each of whom must offer coverage to multiple patients. The number of patients can vary, of course, based on the size of the employer and availability of alternative coverage plans (e.g., alternative healthcare providers). In the case of a large employer with few alternative coverage plans, the healthcare provider may be responsible for managing benefits of a great deal of patients. This situation is further complicated if the healthcare provider extends coverage plans to additional large employers.
When claims are received by the healthcare provider, they must be reviewed to ensure that they are supported by the patient's coverage plan. In the case of prescriptions, immediate approval or denial is required while the pharmacist prepares the prescription. It can be difficult to quickly approve or deny the prescription if the patient's prescription plan includes a large number of restrictions. Further complications arise when the patient requires specialized medication. It is possible to mistakenly support the prescription claim through the coverage plan if a restriction is overlooked. It is also possible to mistakenly deny the prescription claim if a restriction is misinterpreted.
Both situations can prove costly over time. For example, if prescription claims are mistakenly supported, the healthcare provider must absorb the loss rather than bill the client for the cost of covering the prescription claim. On the other hand, if prescriptions are mistakenly denied, clients may become dissatisfied and seek another healthcare provider. Consequently, healthcare providers must exercise care in managing the different coverage plans under their control.
The result of these negotiations is a comprehensive set of treatment and medication coverage rules. The coverage rules define the terms and/or conditions for approving, denying, and appealing coverage of basic and specialized treatment and medications. The coverage rules can be extensive and often must be converted into electronic form to assist in administration of the coverage plan.
Accordingly, there exists a need for a prescription benefits management system that addresses at least some of the current shortcomings of existing systems.
There also exists a need for a prescription benefits management system that allow healthcare providers to easily and efficiently manage multiple healthcare coverage plans.
There exists another need for a prescription benefits management system that minimizes the number and costs of errors associated with processing prescription claims.
There exists a further need for a prescription benefits management system that optimizes the medications and treatments available to patents.
There exists a still further need for a prescription benefits management system that optimizes the cost paid by patients to obtain prescription coverage.